Trends

[Guest guest]

Gene;

First thought was, Are you ok? Are the medications working, or do we need

to consult with your physician? I then realized as I read your post that you

are saying the same thing I have thought for a long time. Although not the top

of the food chain, Amarillo medics do about the same. They spend time on

scene doing treatments instead of going to the hospital. I am not in any way

trying to discredit them (I can just see someone interpreting my comments going

that way).

The rural EMS providers do and have had a great deal of responsibility in

caring for the very sick in the back of their units while enroute 1-2 hours to a

hospital. The rural EMS folks have to stay on top of their game because it

may be 3 months or longer until the knowledge is needed again. Big city EMS is

repetitious, seen it today, done it tomorrow, will see it again in a couple of

days. Burn out does not usually happen in the rural setting unless you and

your wife are the only EMS responders in town. Seen that happen too.

I think you may be onto something. Farmer or Mitch Rancher do not call

EMS for a head ache. If they get a head ache it is from their horse, farm

machinery, or cattle hitting them and by the time EMS arrives " deep in the _ _ _

_ " doesn't even begin to describe what's happening.

I'm right with you.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

[Guest guest]

I hear a resounding RING as the hammer hits the nail. This is why good CE is

so important in the rural areas. Thanks Mr. Grady!

Barry Meffert

In a message dated 3/24/2004 7:58:08 PM Central Standard Time,

wegandy1938@... writes:

While driving the West Texas highways as I frequently do, I have lots of time

to think. Yes, I know that driving and thinking can be dangerous, but I do

it anyway.

Yesterday I read the abstract of the new study that shows that trauma

patients who were ventilated with BVM did better than those who were

endotracheally

intubated. So much for intubation of the trauma victim.

As more and more evidence based studies come online it becomes more and more

apparent that good EMS can be carried on much of the time without Paramedics.

Basic EMTs now can use the Combitube, and ought to be using the Combitube,

can give Epi 1:1000, NTG, aerosol bronchodilators, and defibrillate with the

AED.

This leads me to reconsider the deployment of EMTs and Paramedics.

Currently, Paramedics are concentrated in large urban areas where scene to

hospital transports are likely to be relatively short. There are many fewer

Paramedics per capita in the rural and frontier areas.

The big city Paramedics, at least in the case of Houston, San , and

Dallas, are fire service based. These fire services have been notoriously

poor

at motivating Paramedics toward improved educational standards and improved

standard of care. The existing culture in FD EMS, particularly the larger

ones,

is that medics are 2nd class citizens to firefighters, and are either doing

penance in Hell for sins committed or going through the prescribed years of

Purgatory on their way to a better life as a full time firefighter.

[i would be afraid of being tarred and feathered, drawn and quartered,

beaten, shot, burned, and hanged by some of those medics for making those

statements

except for the fact that there are no medics from any of the large fire

departments who take part in this list. So they'll never know. ]

Big city FD medics do not seek to improve their knowledge base as a rule, do

not seek to improve or expand their clinical skills, and don't want a wider

scope of practice. And why should they? They're so close to good hospitals

that unless they follow the California model of sitting on the scene while

starting IVs and giving their patients manicures and pedicures prior to

transport,

they seldom get to do the advanced skills that they now know how to do.

Therefore, it makes sense to seriously restrict the number of Paramedics in

those services. EMTs with an AED, a Combitube, a Geezer Squeezer and a

mindset for immediate transport can do just about all that's necessary for

those

patients who are going to survive.

If the AED works, flying squad Paramedics arrive to give the

antidysrhythmics if the scene is more than 8 minutes from the nearest

hospital, or after

defibrillating, the EMTs scoop and haul and get them into an ER within that

time.

For those where the AED doesn't work, load and go, do the Combitube and

Geezer Squeezer enroute and get them to the hospital where they can properly

be

pronounced dead.

Paramedics in the flyers would not be firefighters at all, would be a

different category of worker assigned as 3rd service liaison to the fire

service,

would have advanced training, and because there would be relatively few of

them,

they would get to do their advanced stuff often enough to stay in practice.

Their training would be similar to the Australian model which is about 5

times

more comprehensive than most Paramedic education/training in this country.

Paramedics would be sent to calls where medical skills are needed, where

pharmacology will make a difference and IV access is needed, and where

complicated

dysrhythmias are going on and the patient is beyond the selected txp time to

hospital. Paramedics would be deployed around the perimeters rather in the

center of the city so that they could run both in and out. Their deployment

would be mostly limited to call locations where transports to hospital would

be

more than a few minutes.

Fire services would send nobody to Paramedic school, but they might add IV

access by saline lock to the basic skills, thereby often having access

immediately available either to responding Paramedics or to hospital ER

personnel.

Much training money would be saved and EMTs could be rotated on and off the

ambulances much more easily since their skills sets would be less. EMTs have

always had great extrication, lifting and moving, and other basic skills.

There would be no need for them to worry about going much further than that.

Thus, the Paramedic concentration would shift from city where it is not

needed, to country, where it is.

Rural services have a much greater need for Paramedics with advanced

assessment, diagnostic, and clinical skills than are usually needed in large

cities,

simply because they are often looking at transport times of anywhere from

half

an hour at best to 2 or 3 hours. Much more pharmacology is used by those

medics, and although they do not get as many calls as big city medics, the

calls

they do get tend to more likely be seriously sick people. Therefore

Paramedics

are needed more in the rural areas.

The rural paramedics I know are by and large a lot better educated and better

practitioners than the large city FD Paramedics I have witnessed in action.

They HAVE to be better because they've got their patients for a Loooooong

time

and they are apt to be Reeeeally sick. Most of the rural medics I know study

relentlessly, spend lots of time between calls looking up cool EMS stuff on

the Internet and talking over calls. They are more interested in their

patients because they are not as fatigued every shift and not as burnt out.

They

also may know their patients as neighbors, which is a powerful incentive for

excellence.

Yes, exceptions always exist, and generalities are dangerous, but generally

speaking I think many will agree with me.

So, in sum, I predict that in the next 10 years we'll see a redistribution

of Paramedics from city center to rural areas, and most big city services

will

revert to mostly Basic EMT staffing. Rural areas will finally find a way to

fund better services when governments get on top of the learning curve and

figure it out. Rural EMS costs a pittance of what big cities spend.

Your thoughts?

Mr. Grady

[Guest guest]

And I quote several San Fire Department Paramedics, " we get paid for

what we know, not for what we do. "

Many of them have no inclination to do anything other than " load and go. " IV?

What is that? The just introduced 12 lead monitoring and interpretation for

SAFD Paramedics? WHY? They won't take 2 more minutes to take cardiac pt's to

hospitals with cath labs (you know, where they would actually BENEFIT and SAVE

HEART MUSCLE??) It's all about getting a signed refusal or dumping on the

closest hospital to get back to the station quicker.

The good thing is, they now have these neat computerized paperless run forms

with all kinds of cute little check boxes so they don't have to do as much.

[Guest guest]

From: wegandy1938@...

>>Currently, Paramedics are concentrated in large urban areas where

scene to

>>hospital transports are likely to be relatively short. There are many

>>fewer Paramedics per capita in the rural and frontier areas.

I agree wholeheartedly, but then again, one has to ask why? The biggest

reasons to me are a) bigger city EMS are absorbed into fire with few

exceptions, and bigger city EMS pays more than rural areas with few

exceptions

>>The big city Paramedics, at least in the case of Houston, San ,

and

>>Dallas, are fire service based. These fire services have been

notoriously >>poor at motivating Paramedics toward improved educational

standards and >>improved standard of care. The existing culture in FD

EMS, particularly >>the larger ones, is that medics are 2nd class

citizens to firefighters, >>and are either doing penance in Hell for

sins committed or going through >>the prescribed years of Purgatory on

their way to a better life as a full >>time firefighter.

We also have to remember why EMS was sucked into the FD in the first

place, (increased call volume, allowing for justification of budget) and

understand that it is not JUST the FF/EMT that puts EMS down on the list

of important things to do, right after mop the floor and take out the

trash. But in many instances it is the FF upper echelon that instills

the thought patters. It will take a strong chief to turn this attitude

around, and it'll take some time.

>>[i would be afraid of being tarred and feathered, drawn and quartered,

>>beaten, shot, burned, and hanged by some of those medics for making

those >>statements.........

Eventually the burning from the tar will stop......

>>Big city FD medics do not seek to improve their knowledge base as a

rule, >>do not seek to improve or expand their clinical skills, and

don't want a >>wider scope of practice. And why should they?

They have no need to. As a rural medic myself, I enjoy learning and

teaching, at the same time, we have a person in our department who

insists on teaching us new and exciting things. Mind you, we have all

contemplated hanging him by the short hairs at least once or twice for

it, but in the long run, I can assure you that most if not all of us,

are wiser for it. We are aware that our skills don't get used much, and

some times our brains don't get much exercise either.

That said, as much as we may bitch about the things that he teaches us,

and the horrid questions on his tests, our director continues to plod

on, and make us follow him, kicking and screaming sometimes, but we

follow.

Therein lies the difference between us and the 'big city folk'. Our

leader here is insistent upon learning and studying. In the FD's in

larger cities, they put no emphasis on EMS CE, beyond the minimum

required amount.

>>Therefore, it makes sense to seriously restrict the number of

Paramedics >>in those services. EMTs with an AED, a Combitube, a

Geezer Squeezer and >>a mindset for immediate transport can do just

about all that's necessary >>for those patients who are going to

survive.

I agree, many big city services could do well, and reduce budget

overruns by utilizing BLS bus's with Paramedic interceptors.

If the AED works, flying squad Paramedics arrive to give the

>>Rural services have a much greater need for Paramedics with advanced

>>assessment, diagnostic, and clinical skills than are usually needed in

>>large cities, simply because they are often looking at transport times

of >>anywhere from half an hour at best to 2 or 3 hours. Much more

>>pharmacology is used by those medics, and although they do not get as

many >>calls as big city medics, the calls they do get tend to more

likely be >>seriously sick people. Therefore Paramedics are needed more

in the rural >>areas.

>>The rural paramedics I know are by and large a lot better educated and

>>better practitioners than the large city FD Paramedics I have

witnessed in >>action. They HAVE to be better because they've got their

patients for a >>Loooooong time and they are apt to be Reeeeally sick.

Most of the rural >>medics I know study relentlessly, spend lots of time

between calls looking >>up cool EMS stuff on the Internet and talking

over calls. They are more >>interested in their patients because they

are not as fatigued every shift >>and not as burnt out. They also may

know their patients as neighbors, >>which is a powerful incentive for

excellence.

OK, I can't add a thing to this.

>>So, in sum, I predict that in the next 10 years we'll see a

>>redistribution of Paramedics from city center to rural areas, and

>>most big city services will revert to mostly Basic EMT staffing.

Rural >>areas will finally find a way to fund better services when

governments get >>on top of the learning curve and figure it out. Rural

EMS costs a >>pittance of what big cities spend.

You were hitting reality until right about here. As much as I would love

to agree with you here, I have to say I am cynical about the possibility

of rural EMS finding great funding to offer the same benefits that the

bigger cities offer, better CE opportunities yada yada yada.

Good thoughts though......

Mike

[Guest guest]

Gene,

This is same thing I have been saying for the past ten years. I am a

rural Paramedic sidelined by asthma, therefore I teach. Advanced skills and

advanced pharmacology are essential when you are faced with prolonged

transport. Presidio, Texas is 1 1/2 hours away from a small rural hospital

and 4 1/2 hours away from any larger city like Midland or El Paso. They and

Marfa are outside the range of any air ambulance service. Presidio has one

Paramedic, 1 Basic, 1 ECA and one ambulance for a growing town of 6,000 plus

population, two outlying communities and the southern half of Presidio

County. Marfa has 0 full time Paramedics, 2 full time EMT-Is (one of whom is

the director) and 0 full time EMT-Bs and one ambulance for a town of 2,500,

1 outlying community and the northern half of Presidio County. If the

Presidio ambulance is out, Marfa covers the whole county, Presidio, Marfa

and all the outlying communities. Combined the two services run

approximately 800 calls a year with total run times from 3 hours to 6/8

hours duration depending on where the call originated and who has to

respond. Now sit back and do the math and tell me that advanced level care

is not needed in a rural area because we run so few calls.

OK, my soap box is done. Back to setting up for class.

Jeanne E. Amis, RN, LP

Education Director

Marfa City/County EMS

jea@...

Trends

> While driving the West Texas highways as I frequently do, I have lots of

time

> to think. Yes, I know that driving and thinking can be dangerous, but I

do

> it anyway.

>

> Yesterday I read the abstract of the new study that shows that trauma

> patients who were ventilated with BVM did better than those who were

endotracheally

> intubated. So much for intubation of the trauma victim.

>

> As more and more evidence based studies come online it becomes more and

more

> apparent that good EMS can be carried on much of the time without

Paramedics.

>

> Basic EMTs now can use the Combitube, and ought to be using the Combitube,

> can give Epi 1:1000, NTG, aerosol bronchodilators, and defibrillate with

the

> AED.

>

> This leads me to reconsider the deployment of EMTs and Paramedics.

>

> Currently, Paramedics are concentrated in large urban areas where scene to

> hospital transports are likely to be relatively short. There are many

fewer

> Paramedics per capita in the rural and frontier areas.

>

> The big city Paramedics, at least in the case of Houston, San , and

> Dallas, are fire service based. These fire services have been notoriously

poor

> at motivating Paramedics toward improved educational standards and

improved

> standard of care. The existing culture in FD EMS, particularly the larger

ones,

> is that medics are 2nd class citizens to firefighters, and are either

doing

> penance in Hell for sins committed or going through the prescribed years

of

> Purgatory on their way to a better life as a full time firefighter.

>

> [i would be afraid of being tarred and feathered, drawn and quartered,

> beaten, shot, burned, and hanged by some of those medics for making those

statements

> except for the fact that there are no medics from any of the large fire

> departments who take part in this list. So they'll never know. ]

>

> Big city FD medics do not seek to improve their knowledge base as a rule,

do

> not seek to improve or expand their clinical skills, and don't want a

wider

> scope of practice. And why should they? They're so close to good

hospitals

> that unless they follow the California model of sitting on the scene while

> starting IVs and giving their patients manicures and pedicures prior to

transport,

> they seldom get to do the advanced skills that they now know how to do.

>

> Therefore, it makes sense to seriously restrict the number of Paramedics

in

> those services. EMTs with an AED, a Combitube, a Geezer Squeezer and a

> mindset for immediate transport can do just about all that's necessary for

those

> patients who are going to survive.

>

> If the AED works, flying squad Paramedics arrive to give the

> antidysrhythmics if the scene is more than 8 minutes from the nearest

hospital, or after

> defibrillating, the EMTs scoop and haul and get them into an ER within

that time.

> For those where the AED doesn't work, load and go, do the Combitube and

> Geezer Squeezer enroute and get them to the hospital where they can

properly be

> pronounced dead.

>

> Paramedics in the flyers would not be firefighters at all, would be a

> different category of worker assigned as 3rd service liaison to the fire

service,

> would have advanced training, and because there would be relatively few of

them,

> they would get to do their advanced stuff often enough to stay in

practice.

> Their training would be similar to the Australian model which is about 5

times

> more comprehensive than most Paramedic education/training in this country.

>

> Paramedics would be sent to calls where medical skills are needed, where

> pharmacology will make a difference and IV access is needed, and where

complicated

> dysrhythmias are going on and the patient is beyond the selected txp time

to

> hospital. Paramedics would be deployed around the perimeters rather in

the

> center of the city so that they could run both in and out. Their

deployment

> would be mostly limited to call locations where transports to hospital

would be

> more than a few minutes.

>

> Fire services would send nobody to Paramedic school, but they might add IV

> access by saline lock to the basic skills, thereby often having access

> immediately available either to responding Paramedics or to hospital ER

personnel.

>

> Much training money would be saved and EMTs could be rotated on and off

the

> ambulances much more easily since their skills sets would be less. EMTs

have

> always had great extrication, lifting and moving, and other basic skills.

> There would be no need for them to worry about going much further than

that.

>

> Thus, the Paramedic concentration would shift from city where it is not

> needed, to country, where it is.

>

> Rural services have a much greater need for Paramedics with advanced

> assessment, diagnostic, and clinical skills than are usually needed in

large cities,

> simply because they are often looking at transport times of anywhere from

half

> an hour at best to 2 or 3 hours. Much more pharmacology is used by those

> medics, and although they do not get as many calls as big city medics, the

calls

> they do get tend to more likely be seriously sick people. Therefore

Paramedics

> are needed more in the rural areas.

>

> The rural paramedics I know are by and large a lot better educated and

better

> practitioners than the large city FD Paramedics I have witnessed in

action.

> They HAVE to be better because they've got their patients for a Loooooong

time

> and they are apt to be Reeeeally sick. Most of the rural medics I know

study

> relentlessly, spend lots of time between calls looking up cool EMS stuff

on

> the Internet and talking over calls. They are more interested in their

> patients because they are not as fatigued every shift and not as burnt

out. They

> also may know their patients as neighbors, which is a powerful incentive

for

> excellence.

>

> Yes, exceptions always exist, and generalities are dangerous, but

generally

> speaking I think many will agree with me.

>

> So, in sum, I predict that in the next 10 years we'll see a

redistribution

> of Paramedics from city center to rural areas, and most big city services

will

> revert to mostly Basic EMT staffing. Rural areas will finally find a way

to

> fund better services when governments get on top of the learning curve and

> figure it out. Rural EMS costs a pittance of what big cities spend.

>

> Your thoughts?

>

> Mr. Grady

>

>

>

[Guest guest]

Plumbers normally fix it at your house, not back at the shop. Treatment with

no transport anyone?

Barry Meffert

In a message dated 3/25/2004 9:17:13 PM Central Standard Time,

hatfield@... writes:

Lance,

Nice analogy, but we're not saying we won't send a plumber, what we're

saying is that maybe an apprentice can sort out the problem, saving you

money and leaving the plumber for........well....the septic tank

installation.

Mike

> Here's an analogy to consider: If I called a plumber to fix a dripping

> faucet on my sink and the plumber came over, told me that I didn't need to

> call a plumber for this stupid drip, that I should go to Home Depot and

get

> a new washer and do it myself, that he needed to be available for more

> serious plumbing problems...how long would he be in business do you

think?!?

[Guest guest]

In San , diversion is not a courtesy.

If I hospital is on diversion, they will not accept patients by ambulance

unless you can classify them as " Code III Plus " and if you're going to do that,

you'd better have a damn good reason... They'd better be circling the drain,

and you best not be closer by an inch to nay other hospital, especially if the

other closer one is open...

[Guest guest]

Lance,

Nice analogy, but we're not saying we won't send a plumber, what we're

saying is that maybe an apprentice can sort out the problem, saving you

money and leaving the plumber for........well....the septic tank

installation.

Mike

> Here's an analogy to consider: If I called a plumber to fix a dripping

> faucet on my sink and the plumber came over, told me that I didn't need to

> call a plumber for this stupid drip, that I should go to Home Depot and

get

> a new washer and do it myself, that he needed to be available for more

> serious plumbing problems...how long would he be in business do you

think?!?

[Guest guest]

Lance,

Nice analogy, but we're not saying we won't send a plumber, what we're

saying is that maybe an apprentice can sort out the problem, saving you

money and leaving the plumber for........well....the septic tank

installation.

Mike

> Here's an analogy to consider: If I called a plumber to fix a dripping

> faucet on my sink and the plumber came over, told me that I didn't need to

> call a plumber for this stupid drip, that I should go to Home Depot and

get

> a new washer and do it myself, that he needed to be available for more

> serious plumbing problems...how long would he be in business do you

think?!?

[Guest guest]

Jeanne,

800 calls per year averages to how many calls per day and/or per week?

Going out there and working a shift or two would be a real pleasure so

that way you know how nice it is to have a hospital five minutes away

from you in the city.

Stay safe!!

On Thursday, Mar 25, 2004, at 09:18 US/Central, Jeanne wrote:

> Gene,

>     This is same thing I have been saying for the past ten years.  I

> am a

> rural Paramedic sidelined by asthma, therefore I teach.  Advanced

> skills and

> advanced pharmacology are essential when you are faced with prolonged

> transport.  Presidio, Texas is 1 1/2 hours away from a small rural

> hospital

> and 4 1/2 hours away from any larger city like Midland or El Paso. 

> They and

> Marfa are outside the range of any air ambulance service.  Presidio

> has one

> Paramedic, 1 Basic, 1 ECA and one ambulance for a growing town of

> 6,000 plus

> population, two outlying communities and the southern half of Presidio

> County. Marfa has 0 full time Paramedics, 2 full time EMT-Is (one of

> whom is

> the director) and 0 full time EMT-Bs and one ambulance for a town of

> 2,500,

> 1 outlying community and the northern half of Presidio County.  If the

> Presidio ambulance is out, Marfa covers the whole county, Presidio,

> Marfa

> and all the outlying communities.  Combined the two services run

> approximately 800 calls a year with total run times from 3 hours to 6/8

> hours duration depending on where the call originated and who has to

> respond.  Now sit back and do the math and tell me that advanced level

> care

> is not needed in a rural area because we run so few calls.

> OK, my soap box is done.  Back to setting up for class.

> Jeanne E. Amis, RN, LP

> Education Director

> Marfa City/County EMS

> jea@...

[Guest guest]

I see it more as this person is confiding in me to make him or her feel better.

And who am I? Just a common citizen that was able to educate myself in this

field and chose to be in it to help others in their time of need.

Salvador Capuchino Jr

EMT-Paramedic

Valley EMS

www.valleyems.com

Re: RE: Trends

It's the CP and SOB refusals that scare me... I've told plenty of " I need my

foley emptied " 911 callers in my day that they DID NOT need an ambulance.

There is a difference between BS calls and " it's 3am and I'm pissed off about

having to get out of bed. "

As with anything, there just needs to be accountability for your actions.

[Guest guest]

What ever happened to diversion being a courtesy. If a patient wants to go to a

certain hospital take them there after informing them of the diversion. Is the

patient going to recieve better treatment at their usual hospital or at another

one that they have never been to?

Re: Trends

To all regarding my comment about San paramedics:

I received an e-mail from someone I have a lot of respect for, and have

myself taken courses from in the past. In NO WAY was I commenting about him,

or any

of the other outstanding instructors that I have worked and learned for,

under and with from UTHSC.

The problem with SAFD paramedics laziness and poor patient care is one they

themselves, as individual adults, choose to make. I know there are a lot of

good SAFD paramedics, but there are some that have gotten lazy, and they are

the

ones that make the comments about getting paid for what they know and not what

they do.

This is also a combined growing problem involving the whole hospital

diversion thing. In San , the hospitals are grouped by the region that

they are

in. Say there are 3 hospitals in the " north " region. If 2 of them go on

diversion then the third gets creamed with all the remaining EMS traffic.

There is

a hospital system in San that has recently been bought out by a big

corporation. Big corporations want money, if they allow the ER doctors to go

on

diversion, they lose patients and consequently, money. Simplified, what is

happening is ER's 1 & 2 in the " north " region close, ER 3 is forced to accept

the

fallout. ER 3 is owned by the big corporation, and does not want to leave the

decision to close up to the physicians actually working the ER, they prefer

to have the administrators make it in the interest of lining their own

pockets.

This puts the physicians actually working in ER 3 in a VERY bad position.

They get overloaded with patients not only walking in, but coming in by EMS,

the

floors have no beds, so the ER can't move patients and gets stagnant. The ER

physicians don't have to rooms to treat the patients coming in, therefore,

people that are really sick and need immediate attention can't get it, because

there's nowhere to put them. All the while, EMS continues to bring in more and

more patients, because no one keeps track of how many times any given ER gets

hit in a certain timeframe with ambulances. When the paramedics radio in that

they are transporting to XYZ ER, no one in the dispatch center says, " No, why

don't you divert to ABC ER instead, because XYZ has been hit with 5 other

units

in the last 30 minutes? " But we're not just talking about SAEMS, you figure

there are anywhere from 10-15 private ambulance companies that are also

transporting patients to the ER.

Granted, this is not a problem with SAFD, or any of their staff, nor is it a

new problem due to the takeover by the " big corporation. " It's one that has

been and has just continued to grow, and puts a lot of good physicians, and

their licenses in danger. Not to mention the welfare of the patients that are

already in the ER, and the ones trying to get in rather it be by ambulance or

walk-in.

While we're bitching about the way things run, I think this is an issue that

needs to be addressed. Forget the money, EMS is a circle of physicians, EMS

providers and patients, when one part of the circle gets broken, the other

parts

suffer.

WHY CAN'T WE JUST ALL GET ALONG????

To that particular staff member of the UTHSC though, I was not making any

specific reference to you or you staff. You have no control over what the FD

proper, or any of it's members do after they complete your program.

[Guest guest]

I remember of a lawsuit once where trauma 3 hospital was on diversion and trauma

4 was open. Ambulance was enroute with a trauma pt. I do not know the extent of

injuries. Level 3 refused and level 4 accepted. Pt died. Level 3 was sued for

diverting a pt they were equipped to handle. Level 4 was sued for accepting a pt

they knew they could not handle. Ambulance service sued for listening to the

diverting hospital. What can be made of this?

Re: Trends

In San , diversion is not a courtesy.

If I hospital is on diversion, they will not accept patients by ambulance

unless you can classify them as " Code III Plus " and if you're going to do

that,

you'd better have a damn good reason... They'd better be circling the drain,

and you best not be closer by an inch to nay other hospital, especially if the

other closer one is open...

[Guest guest]

This is not just a SAFD problem. Most of the big FD based EMS systems have

this problem. I have seen Dallas FD in action and it scares the $% & *^ & @#

out of me. I pray to god that nothing happens to me when I am in Dallas.

I have seen some of the smaller FD based EMS systems work great.

Ed Walsh LP

Re: Trends

> And I quote several San Fire Department Paramedics, " we get paid

for

> what we know, not for what we do. "

>

> Many of them have no inclination to do anything other than " load and go. "

IV?

> What is that? The just introduced 12 lead monitoring and interpretation

for

> SAFD Paramedics? WHY? They won't take 2 more minutes to take cardiac pt's

to

> hospitals with cath labs (you know, where they would actually BENEFIT and

SAVE

> HEART MUSCLE??) It's all about getting a signed refusal or dumping on the

> closest hospital to get back to the station quicker.

>

> The good thing is, they now have these neat computerized paperless run

forms

> with all kinds of cute little check boxes so they don't have to do as

much.

>

>

>

[Guest guest]

I'd second that. Most of these people just want some reassurance and a fix.

Probably many of these people would welcome a 'house call' instead of having to

go to the hospital.

Meredith

Re: RE: Trends

Plumbers normally fix it at your house, not back at the shop. Treatment with

no transport anyone?

Barry Meffert

In a message dated 3/25/2004 9:17:13 PM Central Standard Time,

hatfield@... writes:

Lance,

Nice analogy, but we're not saying we won't send a plumber, what we're

saying is that maybe an apprentice can sort out the problem, saving you

money and leaving the plumber for........well....the septic tank

installation.

Mike

> Here's an analogy to consider: If I called a plumber to fix a dripping

> faucet on my sink and the plumber came over, told me that I didn't need to

> call a plumber for this stupid drip, that I should go to Home Depot and

get

> a new washer and do it myself, that he needed to be available for more

> serious plumbing problems...how long would he be in business do you

think?!?

[Guest guest]

In a message dated 3/26/2004 7:54:44 AM Central Standard Time,

ultrahog2001@... writes:

Does everyone transport every patient you medicate to the ER? 25 g

of D50-patient is now A & Ox4, just got a little out of whack. Breathing

treatment with 0.3 mg of epi. Patient A & Ox4, lungs clear, O2 98%.

We give meds. We transport. Why? Financial issue. If we don't transport

its awful hard to get reimbursed for what we do. I would love to treat'em and

leave'em if we could.

Do all of these

patients need to go to the ER? Some patients call because their car is

broke,

ran out of meds, or some other problem. They all should get the same

assessment and care but do they need transport to back log an already

understaffed ER?

If we could use the doc-in-the-box clinics and return the ER to what it is

supposed to be the world would be rosy. Thoughts?

Taking the minor stuff to a minor clinic would be nice. Again, Financial

considerations.. what insurance company would pay for that transport?

Just my humble little old opinion. My thoughts and ramblings represent no

one but myself.

Tom LeNeveu

Learning Paramedic

[Guest guest]

Around here, divert status means closed... PERIOD. They have they option to

pick and choose (i.e., we're closed to monitors, neuro, etc.) but if they're

off to all, they're off to all.

If they pt requests to go there, you have to explain to them that their

hospital of choice is not accepting patients by ambulance (which usually ensues

a

LONG discussion). Most times they'll agree to go somewhere else, or they'll go

POV. If lets say they're coding though and XYZ ER closest AND their hospital

of choice, by all means, they qualify as " CODE III PLUS " and you can take them

there. (Still with plenty of bitching and moaning from the ER staff. )

You cannot be charged with kidnapping, they requested your services and you

are not responsible for the bill. It would be as if they were on vacation and

needed EMS. You would not transport them 200 miles to their " home " hospital,

and their insurance has provisions for situations like this.

It's not an EMTALA violation unless the patient is the hospital grounds

already and then they refuse them.

Hopes this helps....

[Guest guest]

I would like to make some brief comments on Gene's original statement. I

appreciate his line of thinking in that he believes this would do the most good

for the most patients. I agree the rural and frontier areas deserve much

attention. This could be started by shifting grant monies from being given to

the larger cities. It appears many times that grants are awarded to these larger

entities so that it " appears " that they are being fair and not just playing to

the volunteer and small community services. Should a large city with millions in

its budget be awarded tens of thousands more, or should it go to an all

volunteer department trying to scrape by with donations and bake sales and 14

employees? Seems simple to me.

I believe that his theory was started after reviewing some of the published

studies. We should be careful and not make sweeping changes to our treatment and

systems based on the data of one or a few studies. Rather, these things should

be surveyed over a period of time and the eventual decision is based on what is

right for our patients. Most importantly, the citizenry of your community

decides the level of service that you provide. If they wish you to be staffed to

the hilt with the most current prehospital practices and highest level of

provider, that's what they will pay for. If not, they will run the majority as

BLS units with some ALS or MICU units.

Be careful in painting the fire based EMS systems with all one brush stroke. I

did my paramedic internship in Dallas and can attest partially with what he

says. In my station and shift, some could not care less about being on " the box "

and went through the motions every shift, but one guy in particular joined the

department just so he could be a medic. Needless to say, he was very

knowledgeable and professional and took me under his wing to make sure I was

learning the proper way.

One of the larger issues is developing the smaller and volunteer EMS systems so

that higher levels of certification and licensure are there, adequately trained

and compensated. Training is one of the first areas to get hit budget-wise and

gets side tracked when more important issues arise. Some of the smaller agencies

don't have full-time training officers. This oversight is even worse in

volunteer departments for the most part.

I wholeheartedly agree the EMS Basic skill level should be advanced, but then we

as a " profession " should advance as well. Maybe the newly formed TDH or an

independent consultant group could mail a questionnaire to every provider in the

state to assess staffing levels, certification/licensure, budget, level of care,

and critical need. This could also be done anonymously through a website link so

that no one would be in fear of speaking " officially " and receiving the wrath of

the employer who would try to sugar coat the response.

Just my individual thoughts. It's a good road to start on to see where it leads.

Who knows maybe we could effect long term change.

Lt. Steve Lemming, AAS, LP

This e-mail is confidential and intended solely for the use of the individual(s)

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Trends

While driving the West Texas highways as I frequently do, I have lots of time

to think. Yes, I know that driving and thinking can be dangerous, but I do

it anyway.

Yesterday I read the abstract of the new study that shows that trauma

patients who were ventilated with BVM did better than those who were

endotracheally

intubated. So much for intubation of the trauma victim.

As more and more evidence based studies come online it becomes more and more

apparent that good EMS can be carried on much of the time without Paramedics.

Basic EMTs now can use the Combitube, and ought to be using the Combitube,

can give Epi 1:1000, NTG, aerosol bronchodilators, and defibrillate with the

AED.

This leads me to reconsider the deployment of EMTs and Paramedics.

Currently, Paramedics are concentrated in large urban areas where scene to

hospital transports are likely to be relatively short. There are many fewer

Paramedics per capita in the rural and frontier areas.

The big city Paramedics, at least in the case of Houston, San , and

Dallas, are fire service based. These fire services have been notoriously poor

at motivating Paramedics toward improved educational standards and improved

standard of care. The existing culture in FD EMS, particularly the larger ones,

is that medics are 2nd class citizens to firefighters, and are either doing

penance in Hell for sins committed or going through the prescribed years of

Purgatory on their way to a better life as a full time firefighter.

[i would be afraid of being tarred and feathered, drawn and quartered,

beaten, shot, burned, and hanged by some of those medics for making those

statements

except for the fact that there are no medics from any of the large fire

departments who take part in this list. So they'll never know. ]

Big city FD medics do not seek to improve their knowledge base as a rule, do

not seek to improve or expand their clinical skills, and don't want a wider

scope of practice. And why should they? They're so close to good hospitals

that unless they follow the California model of sitting on the scene while

starting IVs and giving their patients manicures and pedicures prior to

transport,

they seldom get to do the advanced skills that they now know how to do.

Therefore, it makes sense to seriously restrict the number of Paramedics in

those services. EMTs with an AED, a Combitube, a Geezer Squeezer and a

mindset for immediate transport can do just about all that's necessary for those

patients who are going to survive.

If the AED works, flying squad Paramedics arrive to give the

antidysrhythmics if the scene is more than 8 minutes from the nearest hospital,

or after

defibrillating, the EMTs scoop and haul and get them into an ER within that

time.

For those where the AED doesn't work, load and go, do the Combitube and

Geezer Squeezer enroute and get them to the hospital where they can properly be

pronounced dead.

Paramedics in the flyers would not be firefighters at all, would be a

different category of worker assigned as 3rd service liaison to the fire

service,

would have advanced training, and because there would be relatively few of them,

they would get to do their advanced stuff often enough to stay in practice.

Their training would be similar to the Australian model which is about 5 times

more comprehensive than most Paramedic education/training in this country.

Paramedics would be sent to calls where medical skills are needed, where

pharmacology will make a difference and IV access is needed, and where

complicated

dysrhythmias are going on and the patient is beyond the selected txp time to

hospital. Paramedics would be deployed around the perimeters rather in the

center of the city so that they could run both in and out. Their deployment

would be mostly limited to call locations where transports to hospital would be

more than a few minutes.

Fire services would send nobody to Paramedic school, but they might add IV

access by saline lock to the basic skills, thereby often having access

immediately available either to responding Paramedics or to hospital ER

personnel.

Much training money would be saved and EMTs could be rotated on and off the

ambulances much more easily since their skills sets would be less. EMTs have

always had great extrication, lifting and moving, and other basic skills.

There would be no need for them to worry about going much further than that.

Thus, the Paramedic concentration would shift from city where it is not

needed, to country, where it is.

Rural services have a much greater need for Paramedics with advanced

assessment, diagnostic, and clinical skills than are usually needed in large

cities,

simply because they are often looking at transport times of anywhere from half

an hour at best to 2 or 3 hours. Much more pharmacology is used by those

medics, and although they do not get as many calls as big city medics, the calls

they do get tend to more likely be seriously sick people. Therefore Paramedics

are needed more in the rural areas.

The rural paramedics I know are by and large a lot better educated and better

practitioners than the large city FD Paramedics I have witnessed in action.

They HAVE to be better because they've got their patients for a Loooooong time

and they are apt to be Reeeeally sick. Most of the rural medics I know study

relentlessly, spend lots of time between calls looking up cool EMS stuff on

the Internet and talking over calls. They are more interested in their

patients because they are not as fatigued every shift and not as burnt out.

They

also may know their patients as neighbors, which is a powerful incentive for

excellence.

Yes, exceptions always exist, and generalities are dangerous, but generally

speaking I think many will agree with me.

So, in sum, I predict that in the next 10 years we'll see a redistribution

of Paramedics from city center to rural areas, and most big city services will

revert to mostly Basic EMT staffing. Rural areas will finally find a way to

fund better services when governments get on top of the learning curve and

figure it out. Rural EMS costs a pittance of what big cities spend.

Your thoughts?

Mr. Grady

[Guest guest]

Rev.

Maybe you have an idea here. How about an exchange program. We all

have ideas, skills, etc. that can be shared. Come on out and I'll buy you

an expresso at our local book store. (Yes, we have one, and yes we can read.

LOL)

Jeanne

Re: Trends

Jeanne,

800 calls per year averages to how many calls per day and/or per week?

Going out there and working a shift or two would be a real pleasure so

that way you know how nice it is to have a hospital five minutes away

from you in the city.

Stay safe!!

On Thursday, Mar 25, 2004, at 09:18 US/Central, Jeanne wrote:

> Gene,

> This is same thing I have been saying for the past ten years. I

> am a

> rural Paramedic sidelined by asthma, therefore I teach. Advanced

> skills and

> advanced pharmacology are essential when you are faced with prolonged

> transport. Presidio, Texas is 1 1/2 hours away from a small rural

> hospital

> and 4 1/2 hours away from any larger city like Midland or El Paso.

> They and

> Marfa are outside the range of any air ambulance service. Presidio

> has one

> Paramedic, 1 Basic, 1 ECA and one ambulance for a growing town of

> 6,000 plus

> population, two outlying communities and the southern half of Presidio

> County. Marfa has 0 full time Paramedics, 2 full time EMT-Is (one of

> whom is

> the director) and 0 full time EMT-Bs and one ambulance for a town of

> 2,500,

> 1 outlying community and the northern half of Presidio County. If the

> Presidio ambulance is out, Marfa covers the whole county, Presidio,

> Marfa

> and all the outlying communities. Combined the two services run

> approximately 800 calls a year with total run times from 3 hours to 6/8

> hours duration depending on where the call originated and who has to

> respond. Now sit back and do the math and tell me that advanced level

> care

> is not needed in a rural area because we run so few calls.

> OK, my soap box is done. Back to setting up for class.

> Jeanne E. Amis, RN, LP

> Education Director

> Marfa City/County EMS

> jea@...

[Guest guest]

The way I understand the rules/laws/regulations is that a facility is either

open or closed. If closed, they do not accept any patient. If open, they are

still taking patients. They may place themselves on a divert status while open.

This is a request for EMS units to carry patients to another facility.

Scenario..A patient wants to go to a facility that is on divert. You take them

to another facility although their doctor (and insurance) use their originally

requested facility.

Questions..What charges could a patient bring against you? Kidnapping? Others?

Are you going to be stuck with that bill? Too many others to list....

Hospitals..Are they in violation of EMTALA laws? After all, this patient has

requested treatment in their facility.

Just some crazy thoughts after a long shift....

Neil

cllw602@... wrote:

> In San , diversion is not a courtesy.

>

> If I hospital is on diversion, they will not accept patients by ambulance

> unless you can classify them as " Code III Plus " and if you're going to do

that,

> you'd better have a damn good reason..

And why is that? If you feel like the trauma hospital is where you patient needs

to

go for the appropriate care, then go there. Are they going to tell the gun shot

victim walk in to walk away we are full and on divert. Another thought, Look

at

the bind you are putting the hospital in that you diverted to if they are not

the

appropriate hospital and can not provide the care your patient requires ...No

sir!

I fully understand that the hospital may be up to their neck in patients.

However,

if you go anywhere else other than the appropriate hospital you are not doing

you

job as the patients advocate. You may have to deal with bitches and moans.... so

what you will know that you did the right thing for the patient.

> . They'd better be circling the drain,

> and you best not be closer by an inch to nay other hospital, especially if the

> other closer one is open...

>

I agree if the other hospital is of the same or greater designation. If not, see

paragraph above.

Henry Barber

>

>

[Guest guest]

Re: Trends

The way I understand the rules/laws/regulations is that a facility is

either open or closed. If closed, they do not accept any patient. If

open, they are still taking patients. They may place themselves on a

divert status while open. This is a request for EMS units to carry

patients to another facility.

Scenario..A patient wants to go to a facility that is on divert. You

take them to another facility although their doctor (and insurance) use

their originally requested facility.

Questions..What charges could a patient bring against you? Kidnapping?

Others? Are you going to be stuck with that bill? Too many others to

list....

Hospitals..Are they in violation of EMTALA laws? After all, this patient

has requested treatment in their facility.

Just some crazy thoughts after a long shift....

Neil

No it would not be kidnapping. It would be unlawful retraint if

anything...

B. , LP

Baylor Regional Medical Center at Grapevine

EMS Educator

Baylor EMS Medical Control

400 N. Main St. #104

Grapevine, Tx 76051-3300

Office

Fax

Cell

Cell e-mail 8179925662@...

Hospital Pager

Personal Pager

pager e-mail 8174342094@...

cllw602@... wrote:

> In San , diversion is not a courtesy.

>

> If I hospital is on diversion, they will not accept patients by

ambulance

> unless you can classify them as " Code III Plus " and if you're going to

do that,

> you'd better have a damn good reason..

And why is that? If you feel like the trauma hospital is where you

patient needs to

go for the appropriate care, then go there. Are they going to tell the

gun shot

victim walk in to walk away we are full and on divert. Another

thought, Look at

the bind you are putting the hospital in that you diverted to if they

are not the

appropriate hospital and can not provide the care your patient requires

....No sir!

I fully understand that the hospital may be up to their neck in

patients. However,

if you go anywhere else other than the appropriate hospital you are not

doing you

job as the patients advocate. You may have to deal with bitches and

moans.... so

what you will know that you did the right thing for the patient.

> . They'd better be circling the drain,

> and you best not be closer by an inch to nay other hospital,

especially if the

> other closer one is open...

>

I agree if the other hospital is of the same or greater designation. If

not, see

paragraph above.

Henry Barber

>

>

[Guest guest]

Well...actually...the apprentice can't go to your house without the

licensed plumber there to supervise the work.....and a while back the

plumber couldn't work on the septic tank unless he/she was certified

by the ...get this..TDH( I wonder where that department got shifted

to??)

There use to be only 2 types of plumbing licenses. Now there are

several....mostly probably because of the need for a lower level of

expertise to meet the needs of the construction industry. Why have

someone with the overall understanding of the health and safety

issues that are the real basis of the plumbing industry when we only

need someone to glue pvc pipe together?....Can you say lobby $$$$$$.

Kinda makes you go hmmmmmm....the more things change the more the are

the same.

Steve

> Lance,

>

> Nice analogy, but we're not saying we won't send a plumber, what

we're

> saying is that maybe an apprentice can sort out the problem, saving

you

> money and leaving the plumber for........well....the septic tank

> installation.

>

> Mike

>

> From: " Villers, Lance C " <villers@u...>

>

>

> > Here's an analogy to consider: If I called a plumber to fix a

dripping

> > faucet on my sink and the plumber came over, told me that I

didn't need to

> > call a plumber for this stupid drip, that I should go to Home

Depot and

> get

> > a new washer and do it myself, that he needed to be available for

more

> > serious plumbing problems...how long would he be in business do

you

> think?!?

[Guest guest]

The majority of these patients don't qualify for reimbursement on anyway.

Barry

In a message dated 3/26/2004 8:03:06 AM Central Standard Time,

FireMedic1633@... writes:

In a message dated 3/26/2004 7:54:44 AM Central Standard Time,

ultrahog2001@... writes:

Does everyone transport every patient you medicate to the ER? 25 g

of D50-patient is now A & Ox4, just got a little out of whack. Breathing

treatment with 0.3 mg of epi. Patient A & Ox4, lungs clear, O2 98%.

We give meds. We transport. Why? Financial issue. If we don't transport

its awful hard to get reimbursed for what we do. I would love to treat'em

and

leave'em if we could.

Do all of these

patients need to go to the ER? Some patients call because their car is

broke,

ran out of meds, or some other problem. They all should get the same

assessment and care but do they need transport to back log an already

understaffed ER?

If we could use the doc-in-the-box clinics and return the ER to what it is

supposed to be the world would be rosy. Thoughts?

Taking the minor stuff to a minor clinic would be nice. Again, Financial

considerations.. what insurance company would pay for that transport?

Just my humble little old opinion. My thoughts and ramblings represent no

one but myself.

Tom LeNeveu

Learning Paramedic

[Guest guest]

But they sure would sue to get money if you rendered tx and didn't transport

and they had some kind of reaction, problem, etc.,

[Guest guest]

I posted an article from Fannin County earlier this week which related that

Bonham FD EMS will now have the option of charging $300 for a no transport

call. I don't know what the policy and protocol reads like, but it will be

interesting to see how it works for them.

GG